Long Question

1. Classify non-blood product intravenous fluids with

examples in each
group: (10)
Something along the following lines would be acceptable:
Crystalloids
- Isotonic (Ringers lactate, 0.9% saline)
- Hypertonic (hypertonic saline or 5% saline)
- Hypotonic (Maintelyte)
Colloids
- Gelatin
- Dextrans
- HES
Oxygen carrying solutions
- Haemopure
2. List the adverse effects of 0.9% saline (10)
Febrile response
Infection at site of injection
Venous thrombosis or phlebitis
Extravasation
Hypervolaemia / pulmonary oedema
Abdmonial compartment syndrome
Hyperchloraemia renal dysfunction / GIT dysfunction
Metabolic acidosis
Hypernatraemia
Glycocalyx damage
Inflammatory response
Hyperosmolality
3. In a 60 year old diabetic patient with severe sepsis due to
nosocomial
pneumonia:
a) Discuss your choice of intravenous fluids (not including
blood products) for the perioperative resuscitation and
justify your answer in light of recent evidence. Use the
following headings
i. Physiological goals and measurement (25)
ii. Resuscitation vs Maintenance (Colloids and
crystalloids) (25)
iii. Specific concerns for this patient (use a list)
(10)
b) What haemoglobin trigger would you use and what
target haemoglobin would you aim for when

transfusing the patient? Give reasons for your answer.

(20)
a) There are several headings:
i. Physiological goals here they need to discuss
physiological goals for their fluid management and
include actual numbers of parameters that they
would aim for in this patient.
They can discuss Rivers et al if they like and his
follow-up studies, but essentially I want 2 things:
Specific goals and the means of measuring the
effects of the fluid therapy:
GCS - maintain perfusion and use level of
consciousness as a marker
CVS Systolic > 90, MAP > 65, Pulse pressure >
35
Renal function urine output > 0.5ml/kg/hr
(others could include measured creatinine
clearance, renal biomarkers)
Other biomarkers lactate, SvO2, Base deficit
Euvolaemia mention techniques to assess a
patients volume status (direct vs indirect
measures), and what they would prefer to use
ii.

Resuscitation vs maintenance
For resus, I want them to mention the type of fluid
will they use and how much. In light of the 6S
Sepsis and CHEST trials, I want them to decide if
they will avoid HES and only give crystalloids or
not.
For maintenance fluid requirements, I want them
to tell me the type of fluid and amount and the
principle of replacing daily requirements to pass.
To get more marks they need to discuss daily
electrolyte, and fluid requirements in critically ill
patients

iii.

List specific concerns with this patient

Underlying cardiac dysfunction (elderly diabetic)
Narrow vascular compliance
Right heart dysfunction
Risk of pulmonary oedema
Risk of acute kidney injury and possible need for
dialysis
Fluid overload
Extravasation of fluid resulting in systemic problems
IAH / IACS
GIT failure / difficulty feeding enterally

 Poor wound healing etc

Difficulty in ventilation (increase in extravascular
lung water)
Difficulty weaning ventilation with underlying
cardiac dysfunction
Electrolyte problems with too much 0.9% saline preoperatively
there are others
b) Haemoglobin trigger they will hopefully either choose a low
trigger of 7.0 g/% or a higher trigger of 9g/%.
A low trigger must be justified by the limited evidence that a
higher trigger has not shown benefit in these patients, no
benefit that a higher trigger improves outcome, and that there
is no evidence or mention of comorbid diseases (CVS or
other).
The higher trigger can be justified by mentioning the
underlying cardiac risks for this patient and the TRICC trials
exclusion of certain patient groups. No evidence doesnt mean
no benefit, just no evidence, so this is a line that could justify
their choice.
The target has been included, as I want them to think about
the difference between a trigger and a target and not simply
do what most doctors do and order/give 2 units of blood
regardless of the starting haemoglobin. They need to define
the target according to what they want to achieve. If they
mention a target of >10g/% then this will be difficult to defend
and they will probably lose marks. They may justify a high
target because of the risk of blood loss, for example in a
trauma patient in the initial resus before going to theatre, but
for this patient a target of between 9-10g/% is probably best.
They can discuss optimum Hb levels and oxygen carrying
capacity, viscosity, lack of evidence defining an optimum Hb,
and thus display an understanding of what they are trying to
achieve with the transfusion.